02050107 TINO
CITYBUILDING cDIV siONPERMIT INFCONTRACTOR O TION:
BUILDING ADDRESS: PERMIT NO.
21265 STEVENS CREEK BLVD 02050107
OWNER'S NAME: APPLICATION SUB DATE
STONESON DEVELOPMENT CORP 5/17/2002
PHONE: SANITARY N0, CONTROL NO.
z Z ARCHITECTIENGI,vEER: BUILDING PERMIT INFO
or
BLDG ELECT PLUMB MECH
tw
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed. r provisions of Chapter 9(commencing Job Description
Py� �
with Secean7")ofDivision]anheBuspessandProfessionsCade.andmylicense DEMO ^
E aih,tnryrartean �.
oV Liccn I ss Lic.a
u3_.a.rn Oto c ARCHrrECT'S OF. RATION ®• —
ol
1 understood an,plans shall be used as public records 1 ^p02
Me p e Licensed Professional
OWNER-BUILDER DECLARATION Pk U
1 hereby ifrm that 1 vin exempt from tc C.n,.,.r'a License Law bertha p�
C?¢ following reason.(Section 7031.5,Business and Professions demons CMe:Any citany or county \ p1\Y j O O O
Fx D which requires a permit to construct.alter,improve, olish,or repair y druc utc, 1
a3 "poor to its issuance also requires theapplicant for such paroittu file.signedsmtemem,
Bad, A,Ijq."pagmm!1p�Neprovisions of the Contractors License Law(Chapter9 `rYnry`csy ♦ S• Valuation
(commencingwtth Seniant7W,0I of Division of the Business land prpfessions Code)
or that be is2eempt'thershum and the basis for the albijea emmptp Any violation
-ofSection 7011:5 by my applicant for a permit subjects the applicant to a civil Penalty
.ofnot more than five hundred dollars($580). NO INSPECTI NS`"B"" Occupancy Type
❑1,as owner of the property,or my employees wish wages as their sole compensation,
-'w 11-d the'w h nd'the structure's not'intended do suffered for wile(Sec.9f W;-
'B siredis ond'Pmfcss ons Code The Commctors License law does not apply to an Required Inspections'
caner of property Who budds or improves theman,and who does such work himself
or trough his own employees,ploys,provided that such improvements arc not intended or
r .s .',•r.•.xi .n
ompleti owner-builder ubtle.)r will have the burden of proving that he did not build or `
improve far p pu ryoseo
...O Lniownerof the ,_.r si _. ___. _ . .. ... ._...._...... __._...._. ......... .._. ...._...__ -----
-.
Ptd Kam Business
Professions
Coc:)Tlae munichto
ocense t the project(Sec. to a.Business and Professions ills or The Contre rson. „ t 1.-• ,, •d,t-
l :v::
License law does not apply to an owner of property who builds ala improves thereon.
-.and who. mmn
cas( w. .Projects with.e canuam
cr(s),IicensNrsmm
.puto the-
... omm
CnLa ;
mr's License Low.
_ ❑lam exempt under Seat' _ :B&PC fortisaawn !"It LIZ
Own 11 ,U'te `
WORKER'S COMPENSATION DECLARATION
er Iherebyaifirmanderps, tyorperjury one,ofthe following declarations
p•I have and will,maiiihin a Certificate of Consent to self-insure for Worker's
i Compenmtion, a provided for by Section 3700 mf-the labor Code:for the
_
performance of to wank for which this permit is issued.
I h
ove emid will ni3iniain Worker's Compeniainn Insumn<e,as requite]by Section
00 ofthe'Labor CMe,for the performance of me work for which this permit is
s I Wrkcls Compcmm 1
on los c "t end Policy number a¢
. .n._ p ... _.._......_
cro
t ,I; [RTIFI ATIO�N OF EXWPTION MPEFROM WORKERS}•
CONSATION LVSURANCE 1k.:
(This section need mat be completed if the permit is for one hundred dollars -
(SIM)or Icss)
rtfy that th parfo a- f t work for v pc tis d 1
sM1 ll t-employyy�ippany person in
Yy�1t tut ber so j t the W k rs
._APPi canitt�LRwACf V.IEISR V- is .__. _ _ ._ _. ......
NOTICF/fO APPLICAN f:if.ofermAin,this Cunilicatanf Excmptim,you should -^
Z be b3eci to th Wo&I.C ro ediv p .,ions of the labor Code Yao must
Q Q f rth th' ply with such provisions or this permit shall be deemed mocked.
Zr _ _ .. ..
.tea .' CONSTRUCTION LENDING AGENCY
Ce I hereby alltrm that then is a co cfmn lending agency for the perfumtana
i
�,ti of to work for which this period,is issued ISem.1097,Civ.C.)' ..-_.._...._.___...-.. ...._ ------
Len
-._. .—
QLenJer'a Name." :...'... __. ... . ..._.. ., _ _ _ ._..._ .__._. .__.___.. .._._...._ __ .. _ _
Lenders AJdrtv : •. ••.••. j"b
1 certify that 1 have rtah this application my ordinances
that the above information is
6s..E. to build I agree to comply with all city and county orainanccs and stats laws enter
upon
Q�V t building S t t 1 dh by h c p tali a Tilt':city to t pan
the ahave-mentionscidmpcmyfinspection keep
ap lap, s
„ S (W)agree,. c n fy nikcepheml nth Cty fC pen no dgmnst
V] liabilities,judgments. u is and ex h ch nay nay tree ago t a A v V
Cry neon eq n<e of
he
a ofth pe t ' "
APPLICANT Uv S aYD WILL COMPLY'WITH ALL NON-POI`Yyr
Issued by: r Date
SOURCE RF / ('/Iql
marc of Applicallicimtmew, aerie.. Re-roofs
as J f cdlbtth Cupertino
HAZARDOUS MATERIALS DISCLOSURE _
. applicant future bu Id ng nam p m arc u handle h ',trdom mutenal ...Type Of ROOF _ ....-. ..,....W.... ____... : . . _...
yMunicipal Code.Chirpier 9.12 add the Health and Safety .,
Cmde' it
S trim2553,b.)"' .a l.`.t s.. vt 1 f: ! 1)...t f9
OYx. -/ o s 1, 4 f .
�(" t - All roofs shall be inspected prior to any roofing ma[enal•being installed
` hazardous
Rill theapplicant future builds occupantequipment devices which If a roof is installed without first obtaining an inspection, I agree to remove
th b ; defined the Bay A Quality Management
District? all new materials for inspection Applicant understands and will comply with
ret t as a . . _ - ._..I. . -.. __ .. .
n: -, �N, all non-point source regulations: ,:1, 1I
I have read the hasmdoos materials regmrcmen¢under Chapter 6.95 of the
C l f Health k Safety Code avei ons 25505 25533 and 255341 understand that
fth'b Id gditcs ea temot tout s my responsibility to notify the'
up t f the hick must be met prior us Issuance of to Certificate of
'red, Up Signature of Applicant Date
owner orautaa:ed agent Uma All roof coverings to be Class "B" or better
OFFICE ._. ..-. - . .._ . _.. . . . .. .__ ...._ _.
,i �
CITY OF CUPERTINO rrrtoa'q•yr tia.g':mr-s ... .., ..
BUILDING DIVISION SION CON_ TRAGTO I FMI
BUILDING ADDRESS: PERMIT NO.
21265 STEVENS CREEK BLVD 02050107
OWNER'S NAMR: APPLICATION SUB DATE
STONESON DEVELOPMENT CORP 5/17/2002
PHONE: SANITARY NO. CONTROL NO.
O 6 ARCHITEC(ENGINEER: BUILDING PERMR INFO
BLDG ELECT PLUMB MECH
fs.. LICENSED CONTRACTOR'S DECLARATION
O O M= I hereby affirm that 1 atn licensed u r previsions of Chapter 9(c acing Job Description
Fs�a t: with Secured 7")of Division Sof me Bus�ess and Pmfesxions Cede.and my license DEMO
ffed[ 1 tome an cs. de,
0 a Lice l sls e�1 Lic.p I '�
O a 0 D m Con
ARCHfTECrS DELjON
t u
so 2
01 I understand my plans shall W use u public racerds
sa�so
E.6 p Licensed Prefessional
OWNER-BUILDER DECLARATION
"te-' 1 hereby affirm that I am exempt from the Contractor's License Law for Ne
t Z< f Alo Bing reason,(Section 7031.5.Business sort Professions Code:Any city or county 5 O O 0
E G which requires a permit to construct,.[an,improve,demolish,or repair any swc.re.
ir§ ,prior W its issuance,also requires the applicant fdesuch peanut to Blea signedswtement
Nat hQ l9littnge pursuant t�mp po,nions of the ConwcW(s License faw(Chapter 9 H_jk p[kre Valuation
(commetddVgid,Senjanff0)of Division 3 of the Business pod Qryfesinns Code) .i •;)"v� 12��• 't °.P.4' I2\TATT�'i�'"
or Net he iI MemPr Nertfmm and the basis for the alle¢ed etembop .Any violation
-ofSecuan 70315 by arty oppboam fore permit subjcu da:epplicem m a civil peanity �pp�t,,�,�,t��
ofnot more Nan five hundred do]lars(5500). NO I-[JS'1'li•1G'LrT7 INSPECTI DNS' ' !l
Occupancy Type
❑1.as owner of the property,or my employees with wages as their sole compensation.
"will do the wurk7nd me structure is not intended or offered for side(Sec.7064, - - - - - - - -
'Business and pmfassions Code:The Convenor's License law does not apply W an Required Inspections
ownc
r of property Who builds or improves mercer,and who does such work himself
_or duough his we employees.p...died Nat such improvements arc not intended or
4 8 P -est s soldwithin an year or ... .. ..... . .. . _ ._. . ..
ffmpd for Tale, who the building or "' _
improve meow buldr ill h...dburdenfprovingthat hdid ata build or '
reprove far Purpose of sole.).
❑I o nq of Ne pperty -eadus elY co w t n8 uh I c s d contractors m - - _'- -'
Co..wct the project(Sec.7064,Bus mss and Professions Cade)The Contractor a
Liana Law does and apply to an owner of property who builds or improves mrmon, '
and who contacts far-such Projects wire..commends)licensed pursuant m me.
Conwct&a License L
❑I am exempt under Sec: ;B&P C for mason
Ow Dole
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of me fallowing daclamtions'.
❑ I have and will'mainuin a Certificate of Consent to self-insure for Worker's
Compensation, as provide for by Section 37W of dse labor Cade, for the
penf nsom.of the wark for which Nis permit is issued.
dl have and will mainmin Worker's Compensation Insurance,as required by Section
77(10 of the Labor Code,for me parfermence of the work for which this permit is
issue.M Worked Compensauon Insurance artier end Policy number are:
1.- _ _-. .... .. ..._.... ..- -___.._..._- - ..
uriei:- rr Palic o.:11:.10. Oa{QSOI UItF ; . `
•.'. ERTIFI ATION FE% ON FROMW RK�GRS'; —•-� '. r }[ .,. 11:}; ��•,, �. :• tags:
COMPENSATION INSURANCE ` `
(This section need not be completed tribe permit is for ane hundred dollars
(5100)or less)
1 oenifY that in the performance of Ne work far wyc�hp rrryyy���pe-1 is issued,l
hall'not employ any person in any m_a9nm man to r a Ne Workers
Comyensatioy{pws of Cy'domia.OaK fit/
APPOcant LNAf.! UCI e3RK/• a - . .. .- ._- - __..-
NOTICF/TOAPPLICANT:If,Commrkins this Cisionsof of Labor nyoushould
bca bjccs W the Worker's Compcmauon Period(half Ne Leber Coda you man
Z O forthwith comply with such previsions or anis permit shall be decree revoked.
af� CONSTRUCTION LENDING AGENCY
"> I hereby affirm that there is a convection lending agency for the performance
y O of the wad for which this Permit is issued(Sec.3097,Cm C.) .- -
Under's Name
Z Lender's Address
1 ani fy Nat 1 have read this apph.r.tto and statem
that the above information is
correct,ect,I agree to comply wim all city and county ordinances and sate laws Moling
4.) to building convection,and hereby auarrire representatives of this city to enter upon
�. ora the ad(We)agree to property for inspection pu'rposa.a. /
.F.a (A (s dW
eve,indemnify and kttpt)Trey in
he Cupendus aiainstimt
0 liabilities,judy�s wM1ich may in any wry rccme against said
U Z City in consel reit pe,md
�e APPLICANTDWTLLCOIIPLYWTfHALL60N.POI !
SOURCEa � Issued by: Date
amrc of dppLcar/Commctures 6
HAZARDOUS MATERIALS DISCLOSURE Date
Re-roofs
Will the applicant or f rare building occupant store or handle harmdous material Type.of Roof .. -. ... ....._.._. . . . .... .. .. . _as defined by the Cupertino Municipal Code,Chapur,9.12,and me Health and Safety - - -
Code.Section 25532(a)7, T'o s - ;" ., s♦ .
❑Yes ri - t •' .
All roofs shall be inspected prior to anyroofing material.being,installed.
NLi the applictaminantsa buildingbytheBayAmsAoccupant use irQntor Marta wwhichhen If a roof is installed without fust obtainingan inspection, I agree to remove
emithazardouz an contaminants as defined by the Bay Area Air Quality Management P g
Disuict7 all new materials for inspection. Applicant understands and will comply with
byes AN. all non-point souice'regulations.
I have read the harardous materials requirements under Chapter 6.95 of the
California Health&Safety Cade coons 25505,25537 and 25534.1 mWersund mat
if the building doses ceven tenant,that it is my responsibility to notify the -
ecu am of the which must be met prior to Issuance of a Ccniilcare of
p Signature of Applicant Date
Owner or auNmized agent „� All roof coverings to be Class "B" or better
- - OFFICE
aCity of Cupertino .
w Plan Check Transmittal
Permit# 02050107 Control# 11101
Project DEMO Plancheck# 1
Address 21265 STEVENS CREEK FileDate 5/20/02
Owner JAMBA JUICE
Description
Plan Check Status (attach comments and return to Building with plan set)
Plan
Dept check# Date Due Date Staff Comment Date Approval?
Buildin 1 1 5/20/02 1 6/3/02 1 ❑
Fire I 1 1 5/20/02 1 6/3/02 J-5-- ?-0-
Housing
52U-Housing Mitigation Fee Amount
Heart of the City Specific Plan Fee Amount
U0:LO U: 10::7 0 4U877Y�333 CITY CUPERTINU 41 UU.JU04
• CITY TINO* 6 Z (>S--e� 07
DEMO
CUPE2°r`iNO PERMIT APPLICA ION FORM
APN# Date: t�P
321 -2? -.03C-.) -60
Building Address:
fel a 0,1 SYS S G12ELk, vb 4rrE 2� GV f PFTIOP 1,561+
Owner's e: Phone #:
Mtv0A Jtltc� C,nM fib( At 866 tI71P
Contractor. License#:
To
Contact: Phone#:
Applicant/Contiactor:
Building Permit Info:
'Bldg Elect Plumb Mech
Job Description: y,, ,,K
Residential: Commercial: T tt1rr-0 MUM
Sq.Ft.Floor Area: $/Sq.Ft.-
Architect/En ineer Valuation:
�cxo Qo21� P' o0
• Typc o Construction: Occupan y Group: r2'
�( 2ff ffmr I✓
Qty.if
A licable Fee ID Fee Description Fee Group
1 BPERMFEE Bldg Permit Fees BUILIDNG
1 BSEISMICRE Bldg Permit Fees BUILIDNG
BPLANCHK Plan Check Fee BUILIDNG
BUSLIC Business License BUILIDNG
•
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MAY-15-2002 16:25 \ 4087773333 96: 2
� P.O�